Category Archives: Events

October 22, 2015

Star rankings for doctors who deliver better outcomes in workers’ comp

I was in the audience for a presentation on “outcomes based networks” in workers’ compensation while at the SIIA conference this week (Self-Insurance Institute of America) in Washington DC.   The two presenters were from Sedgwick (which I believe is now by far the largest workers’ comp claims administrator [claims payer] in the country — servicing mostly self-insured employers) and from Multi-Plan (a huge PPO).

The bottom line is that Sedgwick is now putting INDIVIDUAL treating physicians into ranks, from 5 stars (most preferred) all the way down to 1 star (least preferred) .  HOWEVER, many physicians cannot be ranked because the “n” (number of cases for which the payers have data) is too small to analyze with any statistical confidence at all.  The star ratings are NOT generally shared with the physicians — but I bet doctors who know the rankings exist can ask pointed questions about where they stand.

The two speakers have been deeply involved in developing the data sets and metrics to assess physician performance.  They have also been responsible for packaging that information so people who need to know where to send patients can quickly find the best available nearby doctors.  (I am an informed listener on this topic, having developed a physician “report card” myself with less sophisticated data tools in the late 1990’s.)

The presentations were fascinating, both because of what the speakers DID say, as well as what they DIDN’T say.  The four most important things they DID say (if I heard correctly) were that:
•    Sedgwick’s clients, claims adjusters, and case managers who are making referrals / recommending physicians to care for work-related injuries now have access to a user-friendly website that automatically lists doctors within certain geographies IN ORDER OF STAR RANKING (though the ranking itself is not displayed).  Reality check:  Some locations simply don’t HAVE any super-top-ranked providers.
•    Employers who are able to get most or all of their employees to 4 or 5 star doctors have DRAMATICALLY BETTER RESULTS in terms of medical/functional outcomes, disability duration and cost, including higher patient satisfaction/lower litigation rates.   These employers are seeing roughly 15-20% improvement in the parameters of interest.  I heard later that these are mostly California results.
•    The highly ranked doctors are happy to get the referrals and have NOT been asking to be compensated better when it has been confirmed that they are the best.  The highly ranked doctors also tend to be the ones who do a lot of work comp — so they are attuned to the critical issues that need to be managed.  Personally, I think those who DO deliver the best results SHOULD thrive and prosper as a result — not just get more patient volume.  MANY doctors already feel maxed out!
•    A nice endorsement for occupational medicine specialists in general.  The speakers consider “occ docs” as “primary treating” providers (along with urgent care, internists and family practitioners) rather than as specialists (e.g. orthopedists, pain management).  In general, occ docs rank high.  The speakers said it was because of our specialty’s philosophy of care that puts high priority on employing evidence-based techniques for medical treatment and preventing needless work disability in order to optimize patient outcomes and control total episode costs. They said it’s not a sure shot — there are SOME duds in our specialty — but both speakers agreed that as a rule, occ med physicians are among the best.  (They only mentioned occ med because I specifically asked the question –and that was because I suspected what the answer would be –and wanted the audience to hear it!)

The three most important things I DIDN’T hear the speakers say were:
•    How OFTEN the employers/adjusters/case managers are ACTUALLY choosing docs based on rankings.
•    What FRACTION of all doctors in any given geography they actually are ABLE to rank.  (In other words, how many cases have Sedgwick’s employer clients actually been SENDING to each doctor.).  I wouldn’t be at all surprised if it’s less than 25% of the doctors.  I suspect the unranked doctors’ names are NOT presented first.
•    How many cases the doctor has to have treated before ranking them makes sense or is fair. Very few payers are going to have the volume of information available that Sedgwick and Multi-Plan do.  Buyer beware:  TPAs and networks that want to keep up with the Joneses may CLAIM to have ranked providers — but it takes a large number of cases AND considerable statistical sophistication to do this ranking stuff accurately and fairly.   One catastrophic injury could make even a great physician look bad without appropriate adjustment.   The speakers both acknowledged that getting accurate data and analyzing it in a fair manner has been a big challenge, and that their capabilities for doing so have improved rapidly over the last 5 years.

This IS the wave of the future.  Physicians who discover they are low ranked should find out why — and do their level best not to be defensive, but rather learn and improve from the experience.  Buyers of /payers for services absolutely do have the right — if not the duty — to select suppliers based on the best information at hand about who will meet their legitimate needs.   And physicians are suppliers in their eyes.

Sedgwick got started building their Outcomes Based Networks after participating in a Cornerstone Conversation co-hosted by the American College of Occupational & Environmental Medicine (ACOEM) and the International Association of Industrial Accident Boards & Commissions (IAIABC).  This was a four-way conversation among a small group of key stakeholders:  ACOEM leaders, large payers, large employers, and state regulators on what needs to happen in order to improve access to high quality healthcare and improve outcomes for injured workers, and to reduce unnecessary costs for employers and payers.  A joint project undertaken by ACOEM and IAIABC as a result of that meeting was the production of a Guide to High Value Physician Services in Workers’ Compensation.  You may find the observations and suggestions made in this succinct document helpful — whether you are a chooser, a recommender, a payer or a physician-supplier of medical care services.

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October 10, 2015

Some specifics: Our proposal for a Health & Work Service

In our August 2015 proposal to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget on Capitol Hill, we recommended that a community-focused Health & Work Service (HWS) be established.  The services to be provided by the HWS are generally not available in our country today, particularly to lower-wage workers and those who work for small firms.This service would be dedicated to responding rapidly to new episodes of health-related work absence among working people in order to help them:

— Minimize life disruption and get things back to normal as quickly as it is medically safe to do so
— Focus attention on treatments and services to restore ability to function at home and at work
— Understand and navigate through the healthcare and benefits programs and systems
— Avoid being abandoned; learn how to be a squeaky wheel and get their needs met
— Communicate with all parties to expedite both medical care and the return to work process, including resolving non-medical obstacles to recovery and return to work, making temporary adjustments or arranging reasonable accommodation when appropriate.
— Keep their jobs or promptly find new ones if that is necessary.

(The material below summarizes our written proposal.  If you’re interested in the scientific research that underlies these ideas, the 30+ pages and 3 appendices of our “real deal” formal report support all key assertions with literature citations and an extensive bibliography.  Along with the 12 other proposals commissioned by the SSDI Solutions Initiative group, it is scheduled to be published electronically in late October, and in print in January 2016.)

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In the USA today, a large and growing fraction of Social Security Disability Insurance (SSDI) awards are being made to people deemed totally unable to work due to conditions that are among the most common health problems in America and the world, but which only rarely cause permanent withdrawal from the workforce. Low back pain and other chronic musculoskeletal conditions (MSK), and common mood disorders (CMD) —particularly depression and anxiety—are the most prominent conditions in this category.

Near-immediate assistance from a community-focused Health & Work Service will allow people with these kinds of common conditions to avoid the kind of adverse secondary consequences they too often experience today. Those consequences are usually not obvious until months or years later, after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with under-treated or iatrogenic impairment,  become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive. Anticipatory programs that ensure the right things happen from the start and include early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions.

As we envision it, the HWS will build strong collaborative relationships with referral sources in local communities: treating physicians, employers, and benefits payers. Service delivery in individual cases can be largely telephonic and internet-based because these technologies are proving to be as or more effective than face-to-face care delivery. The quadruple goal is to maximize service quality, optimize outcomes, minimize logistical challenges, and control costs. The HWS service will:

(a) — get its referrals from affected individuals, local treating physicians, employers, benefits payers and others when work absence has lasted or is expected to last more than four weeks;

(b) — champion the stay-at-work and return-to-work (SAW/RTW) process from the time of referral through the end of the immediate response period (usually 12 weeks post onset);

(c) —  quickly evaluate the individual’s situation, screen for known risks for poor outcomes, help them make a SAW/RTW plan and support them in carrying it out;

(d) —  facilitate communications among all involved parties as needed to get everyone on the same page and driving towards the best possible outcome.;

(e) — expedite and coordinate external medical, rehabilitative and other kinds of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;

(f) — take a problem-solving approach in collaboration with affected individuals, their treating physicians, employers, and payers.

Of course, developing the HWS will first require a commitment to funding, either by the government or by a foundation that is committed to system change. Once that has been obtained, the initiative will unfold in a series of steps including design, prototyping, development, and field-testing in different geographies, followed by a large randomized controlled trial.  After that, the HWS can gradually roll out across large geographic areas.

What does this mean for you?   First, if you like the idea of working people getting the kind of support they need and deserve — and when it is most likely to make a difference,  please support this idea in whatever way you can.  Why not call or email your Congressman?  Second, if you are a professional with the expertise and passion required to help people get “right back on the horse” — and are now stymied and frustrated by the current system’s inadequacies / dysfunctions, you have probably realized that the HWS service might create a lot of fulfilling and satisfying jobs for specialists like you.  If so…. that’s another reason to call or email your Congressman!

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August 2, 2015

While I was at the White House …..

I was first bewildered then honored to be invited to a White House reception on July 20 to commemorate the 25th anniversary of the ADA.   The invitation was completely unexpected.  It  arrived by email and in the sender field was “The White House”.  I actually wondered for a moment whether it was spam!  I couldn’t figure out HOW my name had gotten on the list — but I went, of course!   It was certainly an experience to remember.  Here are four of my favorite moments.

 

1.  Meeting former Senator Lowell Weicker and his wife — and the surprising result of my little good deed

When the man in the wheelchair to whom I had just introduced myself said that he was former Senator Lowell Weicker (from Connecticut), I asked him why he was here.  He said, “I wrote the ADA.”   Some web research after we got home confirmed that fact:  an ADA Legacy website calls him the “Father of the ADA.” He left the Senate before the significantly amended bill he had originated could be enacted into law.  Senator Weicker also said that writing the ADA was one of the two things that he was most proud of in his entire Senate career.   It was especially poignant to hear this from an 84 year old man in a wheelchair, clearly looking back over his life.

Weickers

About a half hour later, when President Obama started  his remarks, he began by acknowledging the contribution that had been made by various influential ADA big wigs in the room.  Sadly, he never mentioned Senator Weicker.

The next day, I screwed up my courage and sent an email to the White House.  I addressed it to the person who had confirmed our RSVP and arranged our security certification.  Maria’s signature read Associate Director, White House Office of Public Engagement.   The heart of my message read: “I presume that others have alerted you to this issue already, but I believe the President delivered an unintended insult by omission yesterday.   I certainly hope that he apologizes to former Senator Lowell Weicker of Connecticut for failing to publicly acknowledge his presence at the ADA reception yesterday and his enormous contribution as “father” of the original bill that became the ADA.    Personally, I hadn’t been aware of the role Senator Weicker had played, but I just happened to strike up a conversation with him at the event.”

To my ASTONISHMENT, Maria CALLED ME UP a few hours later!  She said they were going to have the President write a letter – and then we had a great chat.  It turns out she is the White House Disability Liaison!   She confirmed that they got my name from the Acting Assistant Secretary of Labor Jennifer Sheehy, in part due to my presentations about the work disability prevention model in various DC forums, and my participation in the Stay-at-Work & Return-to-Work Policy Collaborative sponsored by DOL’s Office of Disability Employment Policy.  Maria also said that they make sure to include some future-oriented people in nostalgic events like anniversaries.  I was finally reassured – my invitation wasn’t a mistake!   And now someone in the actual WHITE HOUSE has heard about our exciting ideas about preventing needless work disability!

 

2.  Here’s proof that medicine was a better career choice for me than photo-journalism

The crowd started gathering to hear the President speak. I decided to avoid the crowd. I stationed myself to catch a close glimpse of him as he was escorted swiftly out of a private corridor into the East Room.  In the excitement, here’s the best / only photo I got– the backs of the heads of the President and Vice-President!   (By the way, as they walked out, I was suddenly reminded that even super powerful people are plain old human beings. For example, their bodies do not glow, have
no visible aura or anything – and there’s no awesome sound track.)

Backs of heads - POTUS, V-POTUS

 

3.  The ADA has transformed lives of people with disabilities — but not everywhere

When it came time for the President to speak, he was introduced by a lively young women from Harvard Law School who is both deaf AND blind. She reminded us that much of the world has no ADA. Her African grandmother has been astonished at what has been possible for her here in the US, since no-one in Africa could imagine such a future for a child like her. She also said that at the beginning, Harvard didn’t know if and how they could accommodate her, but that they were willing to see if they could do it together. Now THAT is the attitude I wish we would hear from more employers!

Woman introducing Obama

 

4.   Looking back while leaving to savor the beauty.

On the walk back down the long hall  to the East Wing exit where we had come in, I snapped a photo of the garden, looking back towards the main White House.  I never dreamed that the most memorable thing about the White House would be its classic beauty.  To my eye, the style of the place evokes the noble yet practical-minded men who founded this country. It also evokes the Age of Enlightenment and the ideas about what it is possible for human beings to be and to become that undergird and sustain this fragile compact with one another that we call a nation. I feel very happy to be part of this continuing American “experiment”.

Garden looking at White House

 

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July 31, 2015

Tell us: Who should be helping workers with health problems keep their jobs?

The US Department of Labor (DOL) wants to engage YOU in dialogue (you employers, insurers, physicians/healthcare providers, managed care companies — and working age individuals whose jobs have been affected by new or changed health conditions.) The dialogue concerns some draft recommendations for Establishing Work and Full Participation in Life as ACCOUNTABLE Health Outcomes.

The recommendations are part of a larger report I have drafted.  It is focused on these questions:
1– How can we reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how can we increase the number who get the help they need to stay employed?
2– What will create widely-shared social agreement that preserving/restoring the ability to work and participate fully in life should be seen as KEY OUTCOMES of healthcare for the working age population?
3– Who should be helping working people KEEP THEIR JOBS after acquiring a new or changed disability?    Who should be held accountable when they needlessly LOSE THEIR JOBS?
4– How can that accountability be established—for real?

The DOL’s Office of Disability Employment Policy (ODEP) commissioned this paper.  Many ideas for how to accomplish those things emerged after interviewing about 20 experts in various fields and discussing these issues with a Policy Work Group within ODEP’s SAW/RTW Policy Collaborative.  Because the stay-at-work and return-to-work process is by nature a “team sport”, the reality is that SEVERAL parties will need to be held accountable.

The draft report actually makes more than 20 detailed recommendations, but for now, ODEP would like to get feedback from YOU on the 6 main ones.  This is a reality check, to see if we’re on the right track in your opinion.   I ENCOURAGE you to disagree, make corrections, or suggest things that are missing or would strengthen the proposal.   The purpose of this exercise is to IMPROVE the report – and increase the chances that it actually has a positive impact.  The ultimate goal is to help more people stay in the workforce, remain productive contributors, and enjoy the many benefits of economic self-sufficiency and full social participation.

You can look at the recommendations on ODEP’s “crowdsourcing” website even before you decide whether to vote/comment.  I hope you will.   See the invitation from ODEP below to get started.   Again, FEEL FREE to disagree, to point out mistakes, make additional suggestions, etc. etc.

From: Acting Assistant Secretary of Labor – Office of Disability Employment Policy
Sent: Wednesday, July 29, 2015 3:40 PM
Subject: ODEP’s Latest Online Dialogue Discusses Work as a Health Outcome

 ODEP epolicyworks masthead 2015-07-31

Second Stay-at-Work/Return-to-Work Online Dialogue:
Establishing Work and Full Participation as Accountable Health Outcomes

Do you have ideas on how to reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how to increase the number who get the help they need to stay employed? If so, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) needs to hear from you!

ODEP is hosting the second in a three-part series of important online dialogues, Establishing Work and Full Participation as Accountable Health Outcomes, to gather input on policy recommendations aimed at establishing work and full participation in life as accountable health outcomes. Through the use of an online crowdsourcing tool, interested stakeholders can provide feedback on these six draft policy recommendations.

Participation is easy. Just review the policy recommendations, register, then share your feedback.

Visit http://WorkAsHealthOutcome.ePolicyWorks.org/ before the dialogue closes on Friday, August 14th. If you have any questions, please contact ePolicyWorks@dol.gov.

Looking forward to your participation,
Jennifer Sheehy
Acting Assistant Secretary of Labor for Disability Employment Policy

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July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.

 

 

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July 7, 2015

#1 of 3 fleeting opportunities to influence policy recommendations

Between now and July 10, you have the first of three time-limited opportunities to preview and maybe influence the recommendations being made in three different policy papers that the Stay-at-Work and Return-to-Work (SAW/RTW) Policy Collaborative is producing this year.  Your input (as an experienced professional in this arena) will make it more likely that their FINAL recommendations are realistic and help accomplish their intended purposes.  Participation is easy.

The dialogue opportunity for the FIRST SET of recommendations will remain open just a few more days — until July 10.   The topic of this first paper is Expanding Access to Evidence-based, Early Intervention SAW/RTW Services and Supports, authored by David Stapleton of Mathematica.  His DRAFT main recommendations have been posted on-line at a “crowdsourcing” website for public review and comment, the National Online Dialogue.

To participate, simply register, read the policy recommendations, give it a thumbs up or down, or go deeper and make a substantive comment.  And please forward this email to any colleagues with an interest in the topic!

The SAW/RTW Policy Collaborative was created to advise the US Dept. of Labor’s Office of Disability Employment Policy (ODEP).   Members are invited by the project contractor, Mathematica, after approval by ODEP.  I have nominated many members all of whom have been accepted (as far as I know).  If you have expertise in this arena and would like to join and actively contribute to the Collaborative, please let me know.

I’m drafting the second policy paper entitled Establishing Work and Participation in Life as Accountable Health Outcomes.  Towards the end of July, my major recommendations will be put into the on-line dialogue.  Y’all come and give my proposals a thumbs up, thumbs down, make a suggestion or leave a comment!   Third in the line-up for dialogue will be the main recommendations from the third paper entitled Job Retention/Creation for Workers Who Experience Productivity Loss by Kevin Hollenbeck from the Upjohn Institute later in the summer.

Before the July 10th deadline, go to this link and provide feedback on Stapleton’s draft policy recommendations:  http://TargetingEarlyIntervention.ePolicyWorks.org/    If you have any questions, please contact ePolicyWorks@dol.gov.   And do remember to let other colleagues know about this SHORT-LIVED opportunity.

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June 18, 2015

Nancy’s super-simple guide to pain

Nancy Grover’s June 15 column on Work Comp Central is a super simple guide to pain for anyone who isn’t really interested in the latest science of neurophysiology — but who wants a basic understanding of how the science of pain is changing our view about how to treat it.

Nancy interviewed me and wrote her column after reading a white paper entitled Red Herrings and Medical Over-Diagnosis Drive Large Loss Workers’ Compensation Claims released by Lockton Companies.  I am one of the co-authors, along with Keith Rosenblum, senior risk consultant at Lockton Companies and Dr. David Ross, a Florida neurologist who is CEO of NeuroPAS Global,

Our goal was to draw attention to an issue that is driving UP costs for payers and driving DOWN quality and outcomes for patients.  In short, all of us (physicians and patients, claims payers, employers, lawyers, judges, etc.) have been getting seduced by the false certainty created by “objective findings” of diagnostic imaging, especially by MRIs.

Before proceeding with invasive procedures and expensive/risky surgeries (that often fail to relieve the pain or create worse problems), we really should be making a good faith effort to identify (and treat) other things that are either causing or worsening the patient’s distress.  Before that first cut is made — are we sure all soft tissue problems have been identified, and then treated by skilled professionals using evidence-based methods?   Have all emotional, psychological, and other human issues known to manifest as bodily distress been identified, and then treated by skilled professionals using evidence-based methods?

If you’re a WorkCompCentral subscriber, read Nancy’s excellent column Low Back Ache: A Pain in the Brain.  If you’re coming to the SIIA conference which is October 18-20 in Washington DC, plan to attend our session on Medical Red Herrings — I’ll see you there!   (SIIA = Self Insurance Institute of America)

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June 17, 2015

Communications Clarity Dept: Useful distinctions

I keep getting reminded how fuzzy words can be — and how much clarity matters to those of us who work across traditional boundaries between specialties, disciplines, or sectors of society.

We just submitted in a paper that will be presented at the McCrery-Pomeroy SSDI Solutions Conference on August 4 and then published later this year.    During the peer review process, it became clear that we, the authors, were confusing readers by using terms differently than they do:  “disability,” “early intervention,” and “recovery” .  So in our new and improved version of the paper, we began by making three key distinctions.  I offer them to YOU, in case they are useful.

Disability vs. Work Disability
According to the ADA, disabilities are impairments affecting major life functions (such as work).  In the world of employment and commercial insurance, work disability is absence from or lack of work attributed to a health condition.  Having a “disability” need not result in “work disability”, a core concept embodied in the Americans with Disabilities Act.   Similarly, having a health problem need not (and usually does not) result in work disability.

What this might mean for you:   Train yourself to add a modifier in front of the word “disability”, especially when you are working with someone in another organization or discipline.    I try to say “work disability” or “impairment disability”– because even if I define how I’m using the word “disability,” people LISTEN their habitual way. 

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process.  Functional restoration refers to re-establishing the usual rhythm of participation in everyday life.  That means the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society.  Functional restoration does not necessarily require medical recovery.  It may include figuring out new ways to accomplish the stuff one needs or wants to do.  So function can be restored through rehabilitation (broadly defined), and can even include the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

What this might mean for you:   Remember to consider these two issues separately in every case.  In order for the affected individual to end up with an optimal outcome, especially when there’s not much to offer on the medical side, paying specific attention to functional restoration is important.

Early Intervention vs. Immediate Response
Our opportunity to influence the occupational outcome of an injury or illness episode DOESN’T really start the day a problem is reported, or the day YOU first get involved. The opportunity clock DOES start on the first day an affected individual stays home from work or admits to having difficulty working – because that is when the period of life disruption and uncertainty starts.    A pro-active work disability prevention program involves immediate response which begins within the first few days and no later than 6 or 8 weeks after onset.  This triggering event (and timeline) is different from the so-called early intervention used in many programs.  In general, those programs start from an administrative date:  claim notification,  date of referral or application for benefits, etc.  It is PATHETIC to see how LATE most referrals for early intervention are ACTUALLY made:  typically 6 or 9 months.   Naturally, the intervener WANTS to look responsive to the paying customer so they hop on the case promptly, within 48 or 72 hours. But hey:  Life moves at the speed of life, you guys, not administrative procedures.

What this might mean for you:   It is inappropriate to let anyone get away with counting from administrative dates — unless you are content with LOOKING responsive rather than BEING helpful.  On EVERY chart or file, keep an on-going record (at every visit or update) of how many days have elapsed since the episode began.  Also include data about how many days it typically takes someone with that particular condition to get back to work.  It will keep your and your collaborators’ feet to the fire.

Personally, when I’m doing my physician version of case management,  I use MDGuidelines.com to keep track of how long the episode SHOULD last, and a website called timeanddate.com to calculate elapsed time to date.   I put those numbers at the top of my reports. This keeps me and my customer REALLY aware of the passage of time, because otherwise, the days just keep slipping away — along with the individual’s chances of EVER going back to work.

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June 12, 2015

First-ever CDC-sponsored “disability prevention” event

Even if you missed it, you can still listen in to a milestone event:   the first-ever public webinar hosted by a federal government agency on the topic of “disability prevention.”   The umbrella hosting agency was the CDC (Centers for Disease Control) which is the main preventive health arm of the Federal government.

The webinar was actually put together and co-sponored by two specialized units buried deep inside the CDC:  the Center for Workers’ Compensation Studies and the Office for Total Worker Health within NIOSH (National Institute of Occupational Safety and Health).  It was an EXCELLENT kick-off  that I hope reflects a sea change and expansion of focus at NIOSH — and maybe eventually the CDC.

Two invited experts spoke about SECONDARY PREVENTION:  mitigating the impact of injuries and illnesses after they occur by preventing adverse consequences.   This is quite different from NIOSH’s traditional focus on PRIMARY prevention:  avoiding the injuries or illnesses in the first place.

The event wasn’t perfect.   Listen carefully and you’ll notice vocabulary problems — a signal that the speakers, the sponsors, and the audience are not yet quite on the same page.   Various people used the word “disability” to describe quite different  things.   For example,  some spoke about  preventing medical or anatomical problems:    obesity, diagnoses, symptoms, anatomic losses and impairments.   The invited outside speakers referred mostly to the dynamic impact of injuries/illnesses on everyday life:  loss of ability, activity limitations, work absence, loss of jobs and livelihoods, descent into a life of poverty and economic dependency.

The speakers’ POWERFUL AND FACT-FILLED presentations with many citations made the nature and extent of the problem of preventable adverse consequences of injuries very clear. They ALSO made it clear that these problems are NOT unique to workers’ compensation.  They are just EASIER to DETECT in comp because both medical AND wage replacement costs are captured in a single dataset.  Even the Q&A portion of the event featured good questions, pithy remarks, and revealing comments from listeners which led to stimulating dialogue.

The featured speakers were:

You can download pdf’s of the speakers’ powerpoint presentations at the end of the webinar.  If you would like a copy of the unedited transcript from the session, please email vqq3@cdc.gov.

Do make time to listen to it!  It will make you think.   Even though I attended the live event, I listened again because the VIIRPM was very high .  [VIIRPM = Very Important Information Rate Per Minute (smile) ].  Here’s a link to the webinar recording (audio plus slides)   https://nioshtwh.adobeconnect.com/p9law27cnd3/.

I’ve been wondering:   What do those vocabulary problems mean for us?  We need to agree on a lexicon, a shared language in which we use terms the same way across all Federal programs and our society (NIOSH, EEOC/ADA, ODEP, Social Security Disability, etc.)  I’ve already suggested a conference on this to the NIOSH people. In addition, we also need an even bigger term to cover ALL the preventable bad stuff that happens in so many domains of life  — and can turn what should have been a short-term hiccup in life into its ruination.   Here’s a laundry list of outcomes we want to avoid:  (a) preventable impairment and functional loss (due to inadequate or ineffective treatment), (b) preventable secondary medical conditions (such as obesity and depression); (c)  iatrogenic illness (such as opioid addiction and drug side effects); (d) over-disabling (due to false beliefs and lack of patient education), (e) avoidable job loss and withdrawal from the workforce, and (f) people leading purposeless lives of social isolation, economic dependency, and poverty who COULD be participating fully in human life!  These are the poison fruits of a system whose gaps and holes reflect a lack of commitment to assuring that the right things happen when a working person’s life is disrupted by injury or illness — no matter the cause.  So, we also need a big term to describe what we DO want to happen, and the better outcomes we want.

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June 8, 2015

Two worthwhile conferences in Chicago this week

Two conferences on worthy topics are going on simultaneously in Chicago this week.   One is a first-time event on a topic that deserves more attention:  the special workplace risks faced by workers with disabilities and their employer’s responsibilities under OSHA and the ADA.  The other is a 35th annual workers’ compensation and occupational medicine event that delivers high quality programs every year.  The profile of attendees at the two conferences also will probably be quite different.  Which one will expand your horizons and be most useful in your career or your service to clients?  Read on, learn more, and take your pick — if you can get to Chicago this week!

To my knowledge, a conference on Promoting Health & Safety for Workers with Disabilities being held on June 9 in Chicago may be the first of its kind.  It explores the implications of the Americans with Disabilities Act (as amended) for workplace safety and health programs.  I predict this will be the bottom line:  Individualized protection plans are a natural part of “reasonable accommodation” — and the need for them should be part of any template for the interactive process.

Beth Marks, RN, PhD, came up with the idea and is the main organizer of the event. Originally trained as a nurse, she believes that people with disabilities who are trying to lead full lives and work deserve support.  She also has personal familiarity with the kinds of unusual workplace hazards faced by workers with vulnerabilities.  Among her many roles, she is co-Director of the National Organization of Nurse with Disabilities (NOND.org)

This event is being hosted by the NIOSH-funded ERC and the NIDRR-funded RRTC at UIC.  It is being co-sponsored by a unique set of organizations:  unions, disability advocacy groups, medical centers and other ERCs,  (Pardon the acronyms:  To fully disclose who is hosting it: the Illinois Occupational and Environmental Health & Safety Education and Research Center funded by the National Institute of Occupational Safety and Health in the School of Public Health at the University of Illinois at Chicago  in collaboration with the Rehabilitation Research and Training Center on Developmental Disabilities and Health in the Department of Disability and Human Development in the College of Applied Sciences at the University of Illinois at Chicago.  Now, is that better? )

The second event is the 35th Annual SEAK Conference on Workers’ Compensation and Occupational Medicine.   Historically held on Cape Cod every summer, this SEAK meeting is being held in Chicago this year while the Massachusetts conference facility is being remodeled.   I have attended, spoken at, and conducted all-day workshops at this annual event many times.  It is an information-rich but not overly academic learning opportunity.  That’s because the focus is on practical application:  how to use information or how to do something important. (SEAK also offers other educational events on more specialized topics.)  The speakers come from a variety of disciplines (medicine, nursing — especially case management, law — including judges, and insurance).  They tend to have deep expertise in their topics, and the pace is lively.  The focus is mostly on the mechanics of workers’ compensation, with less emphasis on wellness, prevention, safety, large issues of social justice, etc.

If you decide to go to one of these events, please let me know which one you attended — and whether it was worth your while!

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